The effectiveness of surprise inspections of health insurance examination and treatment

DNO - Recently, surprise inspections at medical examination and treatment facilities have been considered a breakthrough solution, bringing about clear results in the supervision and management of health insurance funds in Da Nang city.

Examination session at a health insurance facility. Photo: DVCC

Realistic approach

Recently, the Social Insurance (SI) of Da Nang organized a surprise inspection at health insurance facilities. The inspection focused on the supply of drugs, chemicals, medical supplies, medical services, the ability to meet the benefits of health insurance participants as well as the use and management of the health insurance expenditure budget for 2025.

According to Mr. Le Van Tien, Deputy Director of Da Nang Social Insurance, the unit only announces the general plan, the time and location of the inspection is decided by the head or deputy head of the team. "The inspection team will randomly choose the location when boarding the vehicle and will not follow a fixed route to avoid the facilities preparing in advance," said Mr. Tien.

This approach allows the inspection team to approach the reality. Through this, three common groups of violations were recorded. Firstly, some general clinics do not store medical records according to regulations; the arrangement of emergency rooms, patient rooms, and technical service rooms does not meet regulations.

Second, the management of medical equipment and drugs is not in accordance with regulations; there is a mismatch between the records when evaluating medical equipment and the actual use. Third, human resources are not guaranteed, especially doctors, who are registered to practice but are often absent from medical facilities.

In addition to on-site inspections, Da Nang Social Insurance also applies monthly data monitoring to detect abnormalities. According to Mr. Tien, the insurance agency monitors average costs for each facility, comparing them by month, by region and nationwide.

When there is an abnormal increase in the index, the service structure deviates from the regional/national standard, the unit issues a warning to the facility and reports to the Department of Health for coordination in inspection. “This method is very effective, especially with the “peak” costs that fall at the end or beginning of the week,” Mr. Tien commented.

Comprehensive solution

From the inspection practice, Danang Social Insurance proposed many solutions to improve management efficiency. Firstly, regularly conduct surprise inspections instead of relying only on periodic plans.

Second, strengthen coordination with the Department of Health in both appraisal and inspection. The Social Insurance has issued many documents proposing that the Department of Health carefully inspect human resources and equipment before granting licenses to new facilities; at the same time, coordinate general surprise inspections to combine state management and fund appraisal.

Third, apply a data warning system to promptly detect abnormalities, helping management agencies have a basis for checking the right focus, avoiding spreading. Finally, sign a health insurance medical examination and treatment contract with the participation of the Department of Health, ensuring transparency and promptly resolving problems between the social insurance agency and medical facilities.

Mr. Le Van Tien, Deputy Director of Danang Social Insurance.

Mr. Tien also emphasized some long-term policy recommendations: perfecting the planning of the healthcare network according to criteria of density, radius, and regional specialties to avoid widespread investment; strictly controlling licensing conditions, increasing post-inspection; promoting data connectivity to limit duplication of testing and having policies to attract and train high-quality human resources.

Mr. Tien said that in the coming time, the unit will continue to increase the frequency of surprise inspections, while simultaneously assessing records based on probability and risk focus. “The focus of this phase is on general clinics and private healthcare facilities, then gradually expanding to inpatient facilities. We also recommend that the Department of Health increase professional staff to join the delegation to combine state management and fund assessment,” Mr. Tien said.

The surprise inspection model has shown positive results. Not only does it detect violations in a timely manner, it also puts pressure on medical facilities to maintain service quality, aiming for transparency in health insurance fund management.

More importantly, surprise inspections bring peace of mind to health insurance participants, ensure the rights of health insurance card holders when receiving medical examination and treatment, contribute to improving the quality of the health system, and better meet people's health care needs in the new situation.

Source: https://baodanang.vn/hieu-qua-tu-viec-kiem-tra-dot-xuat-cong-tac-kham-chua-benh-bhyt-3303195.html